IDSE Review
Comparison of 2021 IDSA and ACG Recommendations for the Treatment Of C. difficile Infection BY MARK H. WILCOX, MD
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lostridioides difficile infection (CDI) remains a considerable challenge to diagnose accurately, prevent, and treat, especially with respect to minimizing the risk for recurrent infection. In 2021, the Infectious Diseases Society of America (IDSA) and the American College of Gastroenterology (ACG) each updated its own CDI management guideline,1,2 from previous versions published in 2018 (but confusingly noted as a “2017 update”) and 2013, respectively.3,4 Both guidelines used the GRADE criteria to determine the strength of evidence underpinning the recommendations. While the ACG 2021 update is a full series of recommendations covering prevention, diagnosis, treatment, prevention of recurrence, and special populations, the IDSA 2021 update is more focused, given the shorter gap since its previous guidelines. Hence, the IDSA 2021 guideline addresses 3 specific questions (Table 1).1 This review compares and contrasts how the ACG and IDSA cover these 3 key practice points for the treatment of CDI.
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IDSE.NET
Treatment of Initial Episode of CDI The IDSA 2021 guideline recommends fidaxomicin (Dificid, Merck) (200 mg orally given twice daily for 10 days) instead of vancomycin (125 mg orally given 4 times daily for 10 days) to treat an initial episode of CDI (conditional recommendation, moderate certainty of evidence), which is a shift from its previous position.1,3 Furthermore, it is noted this recommendation “places a high value in the beneficial effects and safety of fidaxomicin, but its implementation depends upon available resources. Vancomycin remains an acceptable alternative.”1 Continuing its stance from 2018,3 the IDSA guideline prefers both fidaxomicin and vancomycin to metronidazole, commenting that metronidazole (500 mg orally 3 times daily for 10-14 days) is an alternative for nonsevere CDI, if the former agents are unavailable.1 The IDSA recommendation in favor of fidaxomicin was based on a pooled analysis of 4 studies,5-8 including 2 trials7,8 that were not considered in the 2018 version.3 The Guery
